Reading of the Week: Mass Murder & Mental Illness – the New Psych Med Study; Also, Vaccinations in the EU (Lancet Psych), and Domise on MAiD and His Illness

From the Editor

“Mental illness may have been a factor.”

It’s just seven words, but they so often accompany reports of mass murder. And psychosis is mentioned more often than not. The message is clear: mental disorders, particularly psychotic disorders, are highly tied to violence.

In the first selection, we look at a new paper that reviews 120 years worth of mass murder, and distinguishes between gun violence and non-gun violence. Just published in Psychological Medicine, Gary Brucato (of Columbia University) and his co-authors have written an extraordinary paper. They also reach an important conclusion: “These results suggest that policies aimed at preventing mass shootings by focusing on serious mental illness, characterized by psychotic symptoms, may have limited impact.” We look at the big paper.

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In the second selection, from The Lancet Psychiatry, Dr. Livia J. De Picker (of the University of Antwerp) and her co-authors consider European countries and vaccination prioritization, with a focus on mental disorders. “Only four countries (Denmark, Germany, the Netherlands, and the UK) had some form of higher vaccination priority for outpatients with severe mental illness.”

And, in the third selection, writer Andray Domise considers mental illness and medical assistance in dying. In a personal essay for The Globe and Mail, he raises objections. Start here: he would have opted to die when he was unwell. He argues the whole legislative approach is wrong: “This is a country that continues to fail in respecting the humanity of people with disabilities. And rather than find strength of character to improve ourselves, the Canadian government is set to fall back on egregious historical precedent by offering death instead.”

DG

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Reading of the Week: Cannabis and Inpatients – the New CJP Paper; Also, Alexander on Her Loss and Her Patient’s (JAMA)

From the Editor

First, there was decriminalization; then, legalization.

How have these major legal shifts influenced the presentation of our patients? In the first selection, we consider a new paper from The Canadian Journal of Psychiatry. Taylor McGuckin (of the University of Waterloo) and her co-authors look at cannabis use and inpatient care, drawing on databases. “This study identified a significant increase in the proportion of patients who used cannabis within 30 days of their first admission to inpatient psychiatry in Ontario, Canada, between 2009 and 2017, compared to 2007.”

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How do our biases affect the care we provide? In a moving and personal essay, Karen Alexander (of Thomas Jefferson University) discusses the loss of her baby. She thinks about another time, when a patient of hers was in a similar situation, and she mulls her own views and biases. “The weeping woman was always much more than someone who was grieving, but I never really knew her as a person until I mourned the loss of my own child.”

DG

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Reading of the Week: Lithium vs. Newer Meds for Bipolar – What’s Best? Also, Nudging Vaccines and Beale on Her Illness Experience & Being a Doctor (BMJ)

From the Editor

In the past, lithium had a large role – in the treatment of bipolar, yes, and before that, as a general remedy for a variety of conditions. Indeed, lithium could be found in various things, including pop (see the picture of the ad for 7 Up below). But times have changed. Lithium prescriptions are less common, and bipolar management increasingly involves other medications. (And, no, 7 Up doesn’t contain that salt anymore.)

How does lithium compare to these medications for people with bipolar? Dr. Jens Bohlken (of the University of Leipzig) and his co-authors do a retrospective study drawing on a national database from Germany. “When treatment failure was defined as discontinuing medication or the add-on of a mood stabilizer, or antipsychotic, antidepressant, or benzodiazepine, lithium appears to be more successful as monotherapy maintenance treatment than olanzapine, citalopram, quetiapine, valproate, and venlafaxine.” We look at the big study, and mull its implications on this side of the Atlantic.

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Can we nudge people to vaccinate? As the world works to get more shots in arms, Dr. Mitesh Patel (of the University of Pennsylvania) argues that behavioural economics will be important. In Nature, he writes that we have a golden opportunity to learn from the vaccine roll-out: “Each institution should report its vaccination efforts and performance, and conduct rapid experiments on how best to encourage people to get their vaccines – especially their second doses.”

Finally, some physicians have commented that being touched by illness has helped them become better doctors. Dr. Chloe Beale, a British psychiatrist, agrees to disagree in a blog for BMJ. “I can’t give the expected, tidy narrative of emerging stronger for having my illness.”

DG

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Reading of the Week: Cannabis, Cannabis, Cannabis – With Papers from Psychological Medicine, Psychiatric Services, and Annals of Internal Medicine

From the Editor

“It’s the only thing that works.”

So many of our patients swear by cannabis. It has become a popular choice for everything from anxiety to chronic pain. And though the literature is relatively young, now we know more about cannabis than before. This week, we focus on three new papers.

The first selection is a paper by Dr. Emmet Power (of the Royal College of Surgeons in Ireland) and his co-authors from Psychological Medicine. Does frequent and dependent cannabis use in youth affect IQ? Doing a systematic review and meta-analysis, they find seven papers. They conclude: “We found that young people who use cannabis frequently or dependently by age 18 have declined in IQ at follow up and this may be due to a decline in verbal IQ.”

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In the second selection, we consider a new paper from Psychiatric Services. Dr. Corneliu N. Stanciu (of Dartmouth College) and his co-authors did a systematic review of cannabis for several disorders. “With only eight very small studies, insufficient evidence was found for efficacy of CBD and THC to manage affective disorders, anxiety disorders, or PTSD.”

Finally, in the third selection, we look at a paper from Annals of Internal Medicine. Drs. Arthur Robin Williams (of Columbia University) and Kevin P. Hill (of Harvard University) pose 15 questions about cannabis and answer them. The authors are practical and thoughtful. The clinical bottom line: “Millions more adults now meet criteria for cannabis use disorder in a given year, and all clinicians, not just mental health professionals, have vital roles in improving clinical management, from screening and diagnosis to overseeing treatment plans.”

DG

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Reading of the Week: The New AJP on Alcohol & Subjective Response; Also, Remembering Philip Seeman (Globe) and Sharma on His Godmother

From the Editor

My patient could recognize the damage done by alcohol. The lost friendships. The failed marriage. The firing of her job of 15 years. And yet, she was still puzzled. “How did I get into this mess?”

In a new American Journal of Psychiatry paper, Andrea King (of the University of Chicago) and her co-authors explore the draw of alcohol with a major new study that measures the subjective response to alcohol challenges at five and ten year follow ups. “Initial stimulant and rewarding effects of alcohol predicted heavy alcohol use, and the magnitude of these positive subjective effects increased over a 10-year period in those who developed alcohol use disorder compared with those who did not develop the disorder.” We discuss this big paper.

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Dr. Philip Seeman had an extraordinary career with major achievements. Some argue that he should have shared the Nobel prize. He died on 9 January 2021 at his home. The Globe obituary is our second selection. Dr. Seeman was a generous mentor of many young scientists, and a husband, father, and grandfather. And his work was impactful: Dr. Seeman’s interest in dopamine helped change the way we practice today.

And in our final selection, we look at a new essay by Dr. Gaurav Sharma, a resident of psychiatry at the University of Toronto. The disaster of Ontario’s long term care homes has made many headlines. For this young doctor, the problems are close to home, affecting his godmother. He writes about her life and her downward turn. “In my training as a psychiatry resident, a basic principle I’ve learned is that every mental health crisis has its triggers. In Lucy’s case, the crisis that led to her hospitalization was prompted by a precarious housing situation.”

DG

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Reading of the Week: Yoga vs CBT – What’s Best for Anxiety? (JAMA Psych) Also, COVID & Mental Health (Lancet Psych) and Whitley on Cannabis Stigma (Van Sun)

From the Editor

Anxiety disorders are common, and often disabling to our patients. While treatments have improved, there is unmet need – and the desire to find new, scalable interventions. Increasingly, our patients look to different types of treatments, like yoga. But is trendy effective? Is yoga the not-so-new intervention we need?

Dr. Naomi M. Simon (of New York University) and her co-authors look at the treatment of generalized anxiety disorder with a sophisticated study. They compare yoga and cognitive behavioral therapy (CBT) against a psychological control condition, and against each other. So how do the treatments compare? “Kundalini yoga can reduce anxiety for adults with generalized anxiety disorder, but study results support CBT remaining first-line treatment.” We look at the big study and its big implications.

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What have we learned about COVID-19 and mental health? In the second selection, we consider a new editorial from The Lancet Psychiatry. Mulling the state of the literature after almost a year of the pandemic, they write: “The good news is that by October, 2020, mental health was top of the charts in terms of published papers and preprints on the effects of COVID-19. The bad news is that the quantity of papers is not matched by quality.”

And in our final selection, we consider an essay by Rob Whitley (of McGill University). He notes that 27% of Canadians had used cannabis in the last year, about half of them for medical reasons. He worries about the stigma around medical cannabis and champions more public education. “This can help create a climate of acceptance and inclusion for the growing number of Canadians with mental illness who use cannabis to improve their well-being.”

On another note: in a past Reading, we featured an essay by Toronto filmmaker Rebeccah Love who wrote about her mental illness. Her new film, “Parlour Love,” has its premiere this Saturday at 7 pm EST through Zoom. In this short, powerful film, she draws from her own experiences of bipolar mania and psychosis, and paints a portrait of a woman in crisis. RSVP – palmpremiere@gmail.com.

DG

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Reading of the Week: Alcohol Use, ED Visits & Mortality – the New CMAJ Paper; Also, Dr. Lawrence on Diagnoses and Her Diagnosis (Guardian)

From the Editor:

“He’s here again.”

The staff would roll their eyes. Harold was back. Many of us had encountered him – a person with alcohol use disorder who frequently came to the emergency department of the hospital where I did my internship year. He would usually get a sandwich and a lecture. But what are the outcomes for people like him? And what could be done?

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In the first selection, we consider a new CMAJ paper. Dr. Jennifer Hulme (of the University of Toronto) and her co-authors study outcomes for those presenting to Ontario EDs for alcohol-related reasons. The major finding: “The all-cause 1-year mortality rate was 5.4% overall.” We review the paper and its implications.

In the second selection, we look at a new essay by Dr. Rebecca Lawrence from The Guardian. The UK psychiatrist, who has written about her experiences as a mental health patient, notes the challenges of psychiatric diagnoses. “There are many words in the field of mental illness that have been discarded and are now viewed as stigmatising and inappropriate – words such as ‘cretin’, or ‘lunatic’, or ‘mental’. It’s interesting to consider whether our current crop of acceptable words will end up in that category, and it’s salutary to know that many probably will.”

DG

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Reading of the Week: Vaccines, Vaccine Hesitation & Mental Illness, with Papers from JAMA Psychiatry and NEJM, and More

From the Editor:

It’s here. Less than a year after COVID-19 arrived in North America, two vaccines have been created, approved, and given (at least to some).

In the coming months, as the supply improves, people – including our patients – will have the opportunity to get a vaccine. But what are the challenges? First, some will hesitate. In a recent essay, Dr. Nadia Alam notes that: “Vaccine hesitancy is a significant issue with only 57.5% of Canadians saying they are very likely to be vaccinated for COVID-19.” And special populations will present further challenges – such as those with major mental illness.

This week, we focus on vaccinations with two papers and an article.

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In the first selection, drawing from JAMA Psychiatry, we consider a paper by Dr. Nicola Warren (of the University of Queensland) and her co-authors. They note the challenges of reaching people with serious mental illness – just one in four get a flu vaccine. “It is vital to commence planning and development of appropriate policies to ensure rapid delivery of a COVID-19 vaccine when it becomes available.”

In a New England Journal of Medicine paper, Dr. Joshua A. Barocas (of the Boston University School of Medicine) thinks about the needs of those with substance use disorders. “Officials devising vaccination strategies and allocation plans would be wise to do so from the perspective of the virus, rather than that of stigmatizing personal beliefs.”

How to speak to our patients? In the final selection, we look at a short piece by Dr. Joshua C. Morganstein (of the Uniformed Services University of the Health Sciences).  His advice is very practical, and emphasizes that we should tailor our approach not by diagnosis but by patient interest in the vaccination. He also urges us to be careful in our choice of language: “Health care professionals are trained to use complex medical terminology, though more understandable and down-to-earth language often serves to enhance trust and build rapport.”

DG
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Reading of the Week: The Best of 2020

From the Editor 

It’s a Reading of the Week tradition to begin the new year by reviewing the best of the past one. And so, today, we look back at the selections from the previous 12 months.

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2020 was tough, dominated by the pandemic.

The selections aren’t all about COVID-19, however. Papers shed light on the pandemic, yes, but much research helped further our understanding of mental health, relevant in the world that pre-dated the pandemic, and the world after the pandemic.

Looking over the past year of Readings, I would like to make two observations.

First, about the literature: the overall quality of scholarship remains high. As has been the case year after year, I liked the papers highlighted in this series – but also realize that many more papers could have been picked. Psychiatry continues to grow more sophisticated with each passing year.

Second, about the pandemic: COVID is understood to be a threat to physical health, but also to mental health. As a person with a few grey hairs, I remember SARS well. Mental health wasn’t discussed during that viral outbreak. The public dialogue has changed much in these past 17 years. While I wish more attention were paid to mental health and COVID, there have been national and provincial announcements on the topic, and much media attention too. #Progress

DG

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Reading of the Week: More COVID, More Mental Health Problems? Also, e-Cigarette Use (CJP) and Pappas on Her Olympics & Her Depression (NYT)

From the Editor

Will there be a pandemic after the pandemic? Some have wondered about the mental health consequences of COVID-19 – speculating that, in the future, there will be significant mental health problems. In a recent JAMA paper, Simon et al. argued: “The magnitude of this [mental health] second wave is likely to overwhelm the already frayed mental health system, leading to access problems, particularly for the most vulnerable persons.” (That paper was discussed in a past Reading.)

In the first selection, we consider a new paper from Lancet Psychiatry. Kuan-Yu Pan (of Vrije Universiteit) and co-authors did a survey of people with psychiatric disorders, as well as people without. “We did not find evidence that there was a strong increase in symptoms during the COVID-19 pandemic in those with a higher burden of disorders. In fact, changes in scores from before to during the pandemic indicated increasing symptom levels in people without mental health disorders, whereas changes of symptom levels were minimal or even negative in individuals with the most severe and chronic mental health disorders.” Should we be reassured by the Pan et al. study?

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In the second selection, we consider a research letter from Dr. Scott B. Patten (of the University of Calgary) and his co-authors. Drawing on survey data, they describe the pattern of use of e-cigarettes, noting that they were originally intended for harm reduction. “In 2017, 15.5% of e-cigarette users reported that they had never smoked, suggesting a de novo pattern of substance use. By 2019, this proportion had more than doubled to 36.7%.”

Finally, in the third selection, Olympian Alexi Pappas speaks about her mental health in a New York Times opinion video. The comments are very personal, and touch on her illness and recovery. “After the Olympics, I was diagnosed with severe clinical depression. And it nearly cost me my life. But it doesn’t have to be that way.”

Please note that there will be no Reading for the next two weeks. Enjoy the holidays. And if you are looking for a last-minute gift for, perhaps, Hanukkah or Christmas or a way to thank co-workers after a tough year, consider CAMH’s Pet Therapy Calendar, available for just $15 (with the promotion code). Proceeds go to a good cause: the CAMH Volunteer Resources Pet Therapy Program. The calendar is beautifully done, and features great dogs, including Toulouse (my BFF). Here’s the link: https://store-camh.myshopify.com/products/pvol-cal.

DG

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